55F Carcinoma breast, pleural effusion, heart failure CAD, renal failure Telangana PaJR

09-08-2025

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

[09-08-2025 16.49] PPM 1: 

[11-08-2025 15.07] PPM 1: @PPM3 @PPM4 @PPM5 @PPM6 @PPM7 what is the report of her pleural fluid Hb and PCV?

Pleural fluid tapped by @PPM4 and @PPM6 yesterday.

6th August

7th August

[11-08-2025 15.24] PPM 1: 9th August Saturday chest X-ray.

                                                 

[11-08-2025 20.43] PPM 3: Pleural fluid cytology reports sir
[11-08-2025 20:46] PPM 1: Please see if they can share the actual images

Also what is the report of her pleural fluid Hb and PCV?

[11-08-2025 20:46] PPM 3: Pcv and hb were not done sir

[11-08-2025 20:46] PPM 3: Ok sir

[12-08-2025 10.01] PPM 1: @PPM8 can the LLM diagnose this clinical image? @PPM9 can you? Would be interesting to see who can first!

[12-08-2025 10:05] PPM 9: Was lymph node dissection done? The first thought came to me after reading H/O Breast CA was post mastectomy lymphangitis but isn’t that usually in one hand only? Other cause could be swelling due to heart failure?

[12-08-2025 10:14] PPM 1: Great Web 2.0 inputs for which we were eagerly waiting and wondering what happened to our team oncology enthusiasts!

Yes the image with the left chest scar and lymphedema does conjure up the immediate memory driven flash of carcinomatous lymphangitis and yet why bilateral and not unilateral is the question @Meta AI @PPM8 may help us with.

Also how do we explain her pleural effusion and hemorrhagic fluid drained from one with clear fluid on the other with the clear fluid cytology showing cellular atypia! @PPM3 would you be able to share the images of the cellular atypia from the pathology today other than the Hb PCV pending from our low resource settings lab since Saturday? @PPM10@PPM11 these are the ground level ontologies one needs to optimize?

[12-08-2025 10:14] Meta AI: The case presentation you've shared highlights some intriguing aspects of oncology, particularly with the combination of symptoms and findings. The presence of a left chest scar and lymphedema does suggest a history of cancer treatment, possibly mastectomy and axillary lymph node dissection for breast cancer, which could be a starting point for discussion.

The bilateral nature of the symptoms could indicate either metastasis or a second primary, and the involvement of @PPM8 could indeed provide more insights into the specifics of the case, especially considering the rarity or specifics of bilateral involvement in carcinomatous lymphangitis.

The pleural effusion with differing fluid characteristics (hemorrhagic vs. clear) between the two sides raises several questions:

1. Differential Diagnosis: Could the hemorrhagic fluid indicate malignancy or another process like pulmonary embolism or trauma? Meanwhile, clear fluid with cellular atypia suggests malignancy but might need further specification (e.g., adenocarcinoma, mesothelioma).

2. Cytology and Histology: Requesting images of cellular atypia from the pathology as @PPM3 suggested could help in understanding the nature of the malignancy and guide further management. Given the resource constraints, any available images or detailed descriptions would be invaluable.

3. Ground Level Ontologies: Optimizing ontologies for such cases involves creating a structured framework that can capture specific clinical features, treatments, and outcomes. This would facilitate better data retrieval and analysis for research and clinical decision-making.

Sharing images and detailed reports, as you've requested from @PPM3 and discussed with @PPM10 and @PPM11, would be crucial for a more precise discussion. Given the complexity and the specific findings, a multidisciplinary approach involving oncology, pathology, and radiology might be necessary to piece together the diagnosis and management plan.

[12-08-2025 10:18] PPM 1: @Meta AI She also has renal failure and heart failure since 1 year and that etiology is again uncertain adding to the clinical complexity. One of the main reasons she's currently with us is that we are providing dialysis support

[12-08-2025 10:18] Meta AI: The additional information about renal failure and heart failure adds another layer of complexity to the case. The uncertain etiology of these conditions could be related to the malignancy, treatment side effects, or other underlying conditions. Given the patient's dependence on dialysis support, it's crucial to consider how the cancer treatment and dialysis might interact.

Some potential considerations include:

- Tumor-related renal impairment: Could the malignancy be causing or contributing to the renal failure, either through direct invasion, paraneoplastic syndrome, or other mechanisms?

- Cardio-oncology: The heart failure could be related to the cancer treatment (e.g., cardiotoxic chemotherapy), the malignancy itself, or other factors. A cardio-oncology evaluation might be helpful in determining the etiology and guiding management.

- Fluid management: With pleural effusions and renal failure, fluid management would be critical. Dialysis might help with fluid overload, but it's essential to balance this with the potential impact on the patient's overall hemodynamic status.

- Multidisciplinary care: Given the complexity of this case, a multidisciplinary team involving oncology, nephrology, cardiology, and palliative care would be essential in developing a comprehensive management plan.

It would be helpful to know more about the patient's overall performance status, previous treatments, and any recent changes in their condition. This information could help guide discussions about prognosis, treatment goals, and potential next steps.

[12-08-2025 10:21] PPM 9: @Meta AI can you do a brief literature review and show us similar studies which have been reported previously with more or less similar manifestations?

[12-08-2025 10:21] Meta AI: Cases with similar manifestations have been reported in various studies, highlighting the complexity of pleural effusions in patients with underlying malignancies and comorbidities. Here's a brief overview of relevant findings:

Similar Studies and Manifestations

- Lymphocyte Predominant Exudative Pleural Effusions: A narrative review highlights the diverse etiologies of lymphocyte predominant pleural effusions, including malignancies, infections, and post-cardiac surgery complications. The review notes that these effusions often require thorough evaluation, including thoracentesis and pleural fluid analysis, to determine the underlying cause.

- Pleural Effusions in Cancer Patients: Studies show that malignant pleural effusions are a common complication in cancer patients, particularly those with lung, breast, and lymphoma. These effusions are associated with poor prognosis and require prompt management to alleviate symptoms.

- Carcinomatous Lymphangitis: This rare condition involves the spread of cancer cells through the lymphatic vessels in the lungs, often presenting with bilateral or unilateral pleural effusions. Breast cancer is a common primary malignancy associated with carcinomatous lymphangitis.

- Pleural Effusions in Heart Failure: Pleural effusions are a common finding in patients with congestive heart failure, often presenting as bilateral or right-sided effusions. These effusions are typically transudative, resulting from increased capillary hydrostatic pressure.

Key Findings and Implications

- Prognosis: Malignant pleural effusions are associated with poor prognosis, with a median survival rate ranging from 1.5 to 9 months.

- Treatment: Management of pleural effusions involves addressing the underlying cause, alleviating symptoms, and improving quality of life. Treatment options include thoracentesis, pleurodesis, and palliative care.

- Importance of Early Diagnosis: Early diagnosis and management of pleural effusions are crucial to improving patient outcomes and quality of life ¹ ² ³.

[12-08-2025 10:22] Meta AI: https://careyourlungs.com/exploring-how-pleural-effusion-affects-life-expectancy/

[12-08-2025 10:22] Meta AI: https://epos.myesr.org/poster/esr/ecr2017/C-0300/Findings%20and%20procedure%20details

[12-08-2025 10:22] Meta AI: https://shc.amegroups.org/article/view/7225/html

[12-08-2025 10:49] PPM 1: Morning CBBLE from a PaJR patient shared here earlier (and tagged now) as a quiz:

[12/08, 10:05] PaJR participant: Was lymph node dissection done? The first thought came to me after reading H/O Breast CA was post mastectomy lymphangitis but isn’t that usually in one hand only? Other cause could be swelling due to heart failure?

[12/08, 10:14]cm: Great Web 2.0 inputs for which we were eagerly waiting and wondering what happened to our team oncology enthusiasts!

Yes the image with the left chest scar and lymphedema does conjure up the immediate memory driven flash of carcinomatous lymphangitis and yet why bilateral and not unilateral is the question @⁨Meta AI⁩ @PPM8 may help us with.

Also how do we explain her pleural effusion and hemorrhagic fluid drained from one with clear fluid on the other with the clear fluid cytology showing cellular atypia! @PPM3 would you be able to share the images of the cellular atypia from the pathology today other than the Hb PCV pending from our low resource settings lab since Saturday? @PPM10 @PPM11 these are the ground level ontologies one needs to optimize?

More in the PaJR case report archived 👇

https://pajrcasereporter.blogspot.com/2025/08/55f-carcinoma-breast-pleural-effusion.html?m=1

[12/08, 10:18]cm: @⁨Meta AI⁩ She also has renal failure and heart failure since 1 year and that etiology is again uncertain adding to the clinical complexity. One of the main reasons she's currently with us is that we are providing dialysis support

[12-08-2025 12:16] PPM 8: Based on the clinical details provided, here's a systematic analysis of the case:

### Key Clinical Findings

1. *History*: 55F with:

   - Left mastectomy for breast cancer (scar visible)

   - Bilateral upper limb edema (initially questioned as unilateral vs. bilateral)

   - Bilateral pleural effusions (right hemorrhagic, left clear but with cellular atypia)

   - Concurrent heart failure (etiology unclear), CAD, and renal failure (on dialysis)

   - Pending pleural fluid Hb/PCV results (delayed in low-resource setting)

2. *Critical Questions Raised*:

   - Why *bilateral lymphedema* if post-mastectomy lymphangitis is typically unilateral?

   - How to reconcile *hemorrhagic vs. clear pleural fluid* with bilateral effusions?

   - What explains the *pleural fluid cellular atypia*?

   - Underlying etiology linking breast cancer, heart failure, and renal failure?

---

### Pathophysiological Analysis

#### 1. *Bilateral Lymphedema Mechanisms*

   - *Metastatic Obstruction*: Bilateral edema suggests central lymphatic/vascular obstruction (e.g., superior vena cava syndrome or mediastinal lymph node metastasis).

   - *Systemic Causes*: 

     - Heart failure (↑ venous pressure → bilateral edema)

     - Hypoalbuminemia (renal failure/nephrotic syndrome)

     - Less likely: Bilateral surgical complications (right side unaffected by mastectomy).

#### 2. *Pleural Effusion Discordance*

   - *Right Hemorrhagic Effusion*: Suggests malignancy, pulmonary embolism, or trauma. In breast cancer, hemorrhagic fluid often indicates pleural metastases.

   - *Left Clear Effusion with Atypia*: 

     - *Cellular atypia* on cytology is highly suspicious for malignancy despite clear appearance. 

     - Transudative effusions (e.g., from heart failure) typically lack atypia.

   - *Key Insight: Bilateral effusions with *malignant features imply metastatic disease, even if asymmetric.

#### 3. *Renal-Heart-Cancer Nexus*

   - *Possible Etiologies*:

     - *Chemotherapy Toxicity*: Anthracyclines (e.g., doxorubicin) → cardiomyopathy → heart failure → secondary renal hypoperfusion.

     - *Amyloidosis*: Rare paraneoplastic syndrome in breast cancer causing cardiac/renal involvement.

     - *Metastatic Disease*: Pericardial metastases → heart failure; Renal metastases/obstruction → renal failure.

     - *Vascular Disease*: CAD and renal artery stenosis contributing to cardiorenal syndrome.

---

### Diagnostic Recommendations

1. *Urgent Tests*:

   - *Pleural Fluid Analysis*: 

     - Repeat cytology with *immunohistochemistry* (e.g., GATA3 for breast origin).

     - Measure *Hb/PCV* to confirm hemorrhage vs. traumatic tap.

     - *LDH/Protein*: Differentiate exudate (malignancy) vs. transudate (heart failure).

   - *Imaging*: 

     - *CT Chest/Abdomen*: Evaluate for mediastinal nodes, metastases, vascular obstruction.

     - *Echocardiogram*: Assess LV function (chemotoxicity vs. ischemic cardiomyopathy).

   - *Biomarkers*: BNP (heart failure), Troponin (myocardial injury), Serum free light chains (amyloidosis).

2. *Oncology Workup*:

   - *Tumor Markers*: CA 15-3, CEA.

   - *Biopsy*: If cytology inconclusive, consider pleural biopsy.

---

### Explaining Clinical Paradoxes

| *Finding*          | *Classical Presentation*       | *In This Case*                  | *Rationale*                                  |

|----------------------|----------------------------------|-----------------------------------|-----------------------------------------------|

| Lymphedema           | Unilateral (ipsilateral to surgery) | Bilateral                        | Central obstruction (metastases) or systemic HF |

| Pleural Fluid        | Unilateral in malignancy         | Bilateral with discordant features| Multifactorial: Metastases (R) + HF (L)       |

| Effusion Cytology    | Malignant = hemorrhagic          | Atypia in clear fluid            | Low tumor burden (early metastasis) or sampling error |

---

### Conclusions & Next Steps

- *Probable Diagnosis: **Metastatic Breast Cancer* with:

  - Pleural metastases (bilateral effusions, atypia).

  - Lymphatic obstruction → bilateral edema.

  - Treatment-related or ischemic cardiomyopathy → heart failure → renal failure.

- *Immediate Actions*:

  1. Prioritize *pleural fluid cytology images* and Hb/PCV.

  2. Initiate *CT scan* to identify metastases/lymphadenopathy.

  3. Optimize heart failure management (consider cardioprotective agents if chemotoxicity suspected).

- *Prognosis*: Guarded; hinges on identifying/treating reversible factors (e.g., metastasis vs. cardiotoxicity).

> *Ground-Level Ontology Insight*: In low-resource settings, focus on high-yield tests (cytology, CT) over delayed labs. Cellular atypia in clear fluid is a critical red flag for malignancy despite resource constraints.

[12-08-2025 12:44] PPM 8: Thanks for sharing the image. Based on the visible signs—particularly the pronounced swelling in both hands and forearms—this appears to be a case of bilateral upper limb lymphedema, which can occur in patients with breast cancer, especially following surgery or radiation therapy involving the axillary lymph nodes.

🩺 Possible Clinical Interpretation

Here are some key observations and considerations:

- Swelling and skin changes: The puffiness and taut skin suggest fluid accumulation, likely lymphatic in origin.

- Symmetry: Bilateral involvement may point to systemic or treatment-related causes rather than localized trauma or infection.

- Breast cancer context: 

  - If the patient underwent mastectomy or axillary lymph node dissection, lymphatic drainage from the arms can be impaired.

  - Radiation therapy can also damage lymphatic vessels, contributing to lymphedema.

- Electrodes on chest: Indicates ongoing monitoring, possibly for cardiac or respiratory status—important in advanced cancer care or post-operative recovery.

🔍 Differential Considerations

While lymphedema is most likely, other possibilities include:

- Superior vena cava syndrome (if swelling extends to face/neck)

- Nephrotic syndrome or heart failure (if systemic edema is present)

- Infection (e.g., cellulitis) if redness, warmth, or fever accompanies the swelling

Would you like to explore management strategies for lymphedema in breast cancer patients or dive deeper into the pathophysiology? Copilot

[12-08-2025 12:48] PPM 1: It probably may not have seen the scar on the chest?

[12-08-2025 13:17] PPM 8: It seems so

[12-08-2025 13:18] PPM 8: You're absolutely right to point that out. The image does show what appears to be a surgical scar on the chest, just above the left breast area—likely indicative of a mastectomy. That detail adds significant weight to the diagnosis of post-mastectomy lymphedema.

🔎 Why the Scar Matters

- Surgical history confirmation: A visible scar confirms prior breast surgery, which is a major risk factor for lymphedema due to disruption of lymphatic drainage.

- Laterality clues: If the scar is unilateral but the swelling is bilateral, it may suggest either:

  - Extensive lymphatic compromise

  - Additional factors like radiation or systemic causes

- Clinical staging: The presence of a scar, swelling, and monitoring electrodes suggests the patient may be in a post-operative or surveillance phase of cancer care.

🧠 AI Limitations in Image Diagnosis

While I can interpret visible features and correlate them with clinical context, I don’t “see” in the human sense—I analyze patterns and descriptions. Subtle features like scars, skin texture, or asymmetry can sometimes be missed unless clearly highlighted.

Would you like to explore how lymphedema is staged or managed post-mastectomy? Or perhaps discuss how AI could be trained to better detect such nuanced clinical signs?

[12-08-2025 13:20] PPM 8: Absolutely—AI can be remarkably good at detecting subtle features in medical images, often surpassing human performance in specific tasks. But it depends heavily on how the AI is trained, what kind of data it sees, and how it's applied. Here's a breakdown:

---

🧠 How AI Detects Subtle Features

- Deep learning models (especially convolutional neural networks or CNNs) excel at identifying patterns like:

  - Microcalcifications in mammograms

  - Retinal hemorrhages in fundus images

  - Skin lesion borders and pigment variations

  - Post-surgical scars, edema, or skin texture changes—if trained on such features

- Training data matters: If the model is trained on thousands of annotated images that include scars, swelling, or post-operative changes, it can learn to detect them with high sensitivity.

- Multimodal input: Combining image data with clinical metadata (e.g. history of mastectomy, radiation) improves diagnostic accuracy. AI can then correlate visual signs with known risk factors.

---

⚠ Limitations and Challenges

- General-purpose models (like me) aren't trained on clinical image datasets, so we rely on descriptive cues and pattern recognition—not pixel-level analysis.

- Bias and variability: If training data lacks diversity (e.g. skin tones, surgical techniques), AI may miss subtle features in underrepresented populations.

- Interpretability: AI might detect a feature but not explain it well—this is a key challenge in clinical adoption.

---

🧪 Real-World Applications

| AI Use Case                  | Subtle Feature Detection | Example Tools |

|-----------------------------|--------------------------|---------------|

| Mammography screening       | Microcalcifications, asymmetry | Google’s LYNA, iCAD |

| Dermatology                 | Border irregularity, pigment changes | SkinVision, DermAssist |

| Ophthalmology               | Retinal microaneurysms | IDx-DR, EyeArt |

| Pathology                   | Cell morphology, mitotic figures | Paige, PathAI |

| Radiology (CT/MRI)          | Small nodules, edema, scar tissue | Aidoc, Zebra Medical |

---

Would you be interested in exploring how AI could be tailored to post-mastectomy care—like detecting early lymphedema or monitoring scar healing? Or perhaps how ethical oversight ensures these models remain trustworthy and unbiased?

[12-08-2025 13.34] PPM 8: ### Addressing Your Clinical Queries

#### 1. *Bilateral Lymphedema in Breast Cancer Patient*

   - *Classical Teaching*: Post-mastectomy lymphedema is typically unilateral (ipsilateral arm) due to lymphatic disruption.

   - *Why Bilateral Here?*  

     - *Metastatic Obstruction: Tumor spread to **mediastinal lymph nodes* may cause central lymphatic blockage → bilateral edema.  

     - *Systemic Factors*:  

       • *Heart Failure* (known in this case): ↑ Central venous pressure → bilateral venous/lymphatic congestion.  

       • *Hypoalbuminemia* (renal failure/nephrotic syndrome): Low oncotic pressure exacerbates edema.  

     - *Less Common*: Radiation-induced bilateral lymphatic damage or chemotherapy-related capillary leak.

#### 2. *Bilateral Pleural Effusions: Discordant Characteristics*

   | *Side* | *Fluid Appearance* | *Cytology*      | *Interpretation* |

   |----------|-----------------------|-------------------|-------------------|

   | *Right* | Hemorrhagic          | Not reported      | Classic for *malignancy* (e.g., pleural metastases, tumor erosion of vessels). |

   | *Left*  | Clear                | *Cellular atypia* | Highly suspicious for *malignancy* despite transudative appearance. Atypia may indicate early metastatic involvement or low tumor burden. |

   - *Pathophysiology*:  

     - *Hemorrhagic effusion*: Tumor angiogenesis → fragile blood vessels → RBC leakage.  

     - *Atypia in clear fluid*: Malignant cells may not always cause hemorrhage (e.g., well-differentiated tumors).  

     - *Bilateral effusions: Suggest either **systemic process* (heart failure, hypoalbuminemia) or *advanced metastatic disease* (e.g., contralateral pleural seeding).

#### 3. *Critical Next Steps & Low-Resource Optimization*

   - *Pleural Fluid Cytology Images*:  

     - *@~Sreeteja*: Urgently needed! Atypia in clear fluid is a red flag. Look for:  

       • Clusters of epithelial cells with high N/C ratio.  

       • Irregular nuclear membranes.  

       • Mitotic figures.  

       *(Example: [Breast cancer pleural cytology](https://www.pathologyoutlines.com/topic/pleuracavitymalignantbreast.html))*  

  - *Pending Hb/PCV*:  

     - *Workaround*:  

       1. *Centrifuge* clear fluid → if pink pellet, suggests occult hemorrhage.  

       2. *Dipstick test* for hemoglobin (if lab unavailable).  

       3. Compare *fluid hematocrit* vs. peripheral blood (if >50% serum Hct → true hemorrhage).  

   - *Ground-Level Ontology Optimization* (for @Rahul Kulkarni & team):  

     - *Priority 1: Rule out **metastatic breast cancer* with:  

       • *Ultrasound-guided pleural biopsy* (higher yield than cytology alone).  

       • *Tumor markers* (CEA, CA 15-3) if available.  

     - *Priority 2: Assess **cardiac-renal link*:  

       • *Echocardiogram* (EF? wall motion? pericardial effusion?).  

       • *Urine protein/creatinine ratio* (nephrotic syndrome?).  

     - *Low-Cost Diagnostics*:  

       • *Chest CT* (mediastinal nodes? metastases?) > MRI/PET in resource constraints.  

       • *Pericardial tap* if new effusion suspected.  

#### 4. *Unifying Diagnosis*

   - *Most Likely: **Metastatic Breast Cancer* with:  

     - Pleural metastases (bilateral effusions, atypia).  

     - Lymphatic obstruction → bilateral lymphedema.  

     - Cardiac/Renal involvement: Either:  

       • *Chemotherapy toxicity* (e.g., doxorubicin cardiomyopathy → heart failure → renal hypoperfusion).  

       • *Paraneoplastic syndrome* (e.g., amyloidosis).  

### Action Plan

1. *Immediate*:  

   - Share *cytology images* for expert review (pathologist/oncology team).  

   - Repeat *pleural fluid analysis* with Hb/PCV + LDH/protein.  

2. *Short-Term*:  

   - *CT chest/abdomen* to identify metastases/lymphadenopathy.  

   - *Echocardiogram* + BNP.  

3. *Management*:  

   - If metastatic: Palliative pleural drainage + systemic therapy (hormonal/chemo based on receptor status).  

   - If heart failure primary: Optimize diuretics + dialysis.  

> *Key Insight: The bilateral lymphedema and discordant effusions point to **two concurrent processes*:  

> - *Metastatic disease* (causing lymphangitis/effusions).  

> - *Cardiorenal syndrome* (explaining bilateral edema and effusions).  

> *Diagnostic pivot*: Cytology atypia trumps fluid appearance – clear fluid ≠ benign!DeepSeek

[12-08-2025 15.46] PPM 1: This is her right hand right now before discharge

[12-08-2025 16:02] PPM 9: Why are we discharging sir?

[12-08-2025 16:13] PPM 1: They were advised to meet the oncologist in NIMs

[12-08-2025 16:14] PPM 1: 👆@PPM 8 can your LLM read the cytopathology of this patient from the real images of the cells in her pleural fluid

[12-08-2025 16:31] PPM 8: From the provided microscopic images of the pleural fluid cytology:

* The *first image* shows clusters of cells with hyperchromatic, irregular nuclei. The arrow points to a *binucleated cell* with a high nuclear-to-cytoplasmic (N\:C) ratio, features often seen in malignant cells.

* The *second image* (stained differently) also demonstrates scattered cells with high N\:C ratio and nuclear irregularities in a background of proteinaceous fluid. The arrow indicates a small, darkly stained cell—likely part of the malignant population.

Given the clinical context (*known left breast cancer* with *bilateral pleural effusion), these cytologic findings are highly suggestive of **malignant pleural effusion* due to metastatic breast carcinoma. The pleural involvement is consistent with advanced disease, where tumor cells exfoliate into the pleural space.

To be thorough, cytopathology reports in such cases often:

* Confirm the presence of *malignant epithelial cells* (sometimes with immunocytochemistry like ER/PR/HER2 or CK7 positivity for breast origin).

* Describe nuclear pleomorphism, prominent nucleoli, and irregular nuclear contours.

* Note background findings such as mesothelial cells and inflammatory cells.

If you’d like, I can outline how these images’ cytologic features distinguish *malignant cells* from *reactive mesothelial cells*. That can help in understanding why these findings point to metastatic breast cancer in the pleural fluid.

[12-08-2025 16:32] PPM 8: Alright — let’s break it down step by step, because differentiating *malignant cells* from *reactive mesothelial cells* is one of the trickiest parts of pleural fluid cytology.

---

## *1. Morphology of Malignant Cells (as in your images)*

*Key features visible in your images:*

* *High nuclear-to-cytoplasmic (N\:C) ratio* – The nuclei take up most of the cell volume, as in the binucleated cell in image 1.

* *Nuclear pleomorphism* – Variable shapes and sizes of nuclei, some enlarged and irregular.

* *Hyperchromasia* – Dark, densely stained chromatin, indicating active and abnormal DNA synthesis.

* *Irregular nuclear membrane* – Not smooth; instead, it’s jagged or folded.

* *Mitotic figures* – Occasionally present, indicating cell proliferation.

* *Cell clustering* – Malignant cells often appear in tight, irregular clusters with overlapping nuclei, unlike the more uniform arrangement of mesothelial cells.

* *Background* – Often has necrotic debris or proteinaceous material (as seen in your second image).

---

## *2. Morphology of Reactive Mesothelial Cells*

*Typical features:*

* *Moderate to abundant cytoplasm* – The cytoplasm may be dense and sometimes vacuolated.

* *Low to moderate N\:C ratio* – More cytoplasm compared to malignant cells.

* *Smooth nuclear membranes* – Uniform and round/oval in shape.

* *Central nuclei* – Usually single and centrally placed.

* *Even chromatin* – Fine and uniform without coarse clumping.

* *"Windows" between cells* – When mesothelial cells cluster, small clear spaces are seen between adjacent cells due to cytoplasmic borders (absent in malignant clusters).

* *Uniform size and shape* – Minimal pleomorphism.

---

## *3. Summary Table — What We See Here*

| Feature             | Malignant Cells (seen here) | Reactive Mesothelial Cells       |

| ------------------- | --------------------------- | -------------------------------- |

| *N\:C ratio*      | High                        | Low–Moderate                     |

| *Nuclear contour* | Irregular                   | Smooth                           |

| *Chromatin*       | Coarse, hyperchromatic      | Fine, even                       |

| *Pleomorphism*    | Marked                      | Minimal                          |

| *Clusters*        | Tight, overlapping nuclei   | Loosely cohesive, with "windows" |

| *Binucleation*    | Common, atypical            | May occur but symmetrical        |

| *Background*      | Necrosis, proteinaceous     | Clear, mesothelial cells         |

---

## *4. Why This Matters in Your Patient*

Since your patient has *known breast carcinoma* and now shows:

* Cytologic features of malignancy in pleural fluid

* Clinical context of *bilateral pleural effusion*

  … this is almost certainly *malignant pleural effusion from metastatic breast cancer*.

*Confirmatory step:* Immunocytochemistry (ICC) on the pleural fluid cell block, using:

* *CK7* (positive in breast epithelium)

* *GATA3* (highly sensitive for breast cancer)

* *ER/PR* (to match primary tumor profile)

---

If you want, I can create a *side-by-side labeled diagram* of your image, pointing out exactly which cells are malignant and which are likely benign mesothelial cells. That way, you can visually see the differences.

[12-08-2025 16:35] PPM 8: I’ve annotated the first image to highlight malignant versus likely reactive mesothelial cells:

[📍 View Annotated Image](sandbox:/mnt/data/annotated_image1.jpg)

Do you want me to do the same detailed labeling for the second image?

[12-08-2025 16:37] PPM 8: Scholar ChatGPT 👆

[12-08-2025 17:03] PPM 1: Wow! Amazing! 

Let me also verify these inputs with our pathologists

[12-08-2025 18:54] PPM 1: [12/08, 17:44]cm: Can you help us by sharing the pleural fluid cell block for the above suggested next confirmatory step 👇

Confirmatory step:**

 Immunocytochemistry (ICC) on the pleural fluid cell block, using:

* *CK7* (positive in breast epithelium)

* *GATA3* (highly sensitive for breast cancer)

* *ER/PR* (to match primary tumor profile)

@⁨Meta AI⁩ what's the sensitivity specificity of the above suggested confirmatory step?

[12/08, 17:44] Meta AI: The sensitivity and specificity of Immunocytochemistry (ICC) on pleural fluid cell block for diagnosing malignant pleural effusions, particularly using markers like CK7, GATA3, ER/PR, vary based on several factors.

Sensitivity and Specificity:

-Sensitivity: The average sensitivity of cytological examination of pleural fluid is around 58.2%, ranging from 22% to 81%. ICC can improve sensitivity when used in conjunction with cytology.

- Specificity: The specificity of cytomorphology is generally high, ranging from 91% to 100%, with an average of 97%. ICC markers like CK7, GATA3, and ER/PR can further enhance specificity for diagnosing metastatic breast cancer.¹

ICC Markers:

-CK7: Positive in various adenocarcinomas, including breast cancer.

- GATA3: Highly sensitive for breast cancer, particularly triple-negative breast cancer.

- ER/PR: Useful for matching primary tumor profiles in breast cancer.

Diagnostic Accuracy:

- A study found that liquid-based cytology (LBC) combined with cell block preparations had a sensitivity of 95.35% and specificity of 58.82% in diagnosing malignant pleural effusions.

- ICC on cell block preparations can improve diagnostic accuracy by allowing for multiple sections and special stains.²

Keep in mind that the exact sensitivity and specificity may vary depending on the study population, type of malignancy, and ICC markers used. For more specific information, consult a medical professional or relevant research studies.³

[12/08, 18:27]Pathology: Yes sir 

Immunocytochemistry can be done sir

[12/08, 18:52]cm: Can you provide us that pleural fluid cell block?

[17-10-2025 15.17] PPM 6: https://youtube.com/shorts/q9tBqG5nl3Q?si=tDdgoNXNRdSNufUG

👆 Draining air with a syringe from the pleura

[17-10-2025 15.18] PPM 3: 

👆17/10/25 post intubation 1

👆17/10/25 post intubation 2

[17-10-2025 15.24] PPM 1: Today's update:
[17-10-2025 15.27] PPM 1: https://youtube.com/shorts/js0lKtd7Nf0?si=k0EJ3B2SEPzdK3WI

👆Today's

[17-10-2025 15.28] PPM 1: 

[17-10-2025 15.29] PPM 1: https://youtube.com/shorts/uyowBayI-gs?si=tkryFv3OPG7hZ7gN
[21-10-2025 15.21] PPM 1: Patient update on 18/10/25

[21-10-2025 15.29] PPM 1: Today's update, Switched from SIMV to CPAP ventilation

[4:56 pm, 21/10/2025] PPM 1: Remarkable improvement in the chest X-ray with disappearance of the right hydropneumothorax and left pleural effusion.

@PPM3 what's the pulmonology plan for pleurodesis. Also @PPM13@PPM14 please find out and share the details of her evaluation prior to her mastectomy, radiotherapy and chemotherapy 5 years back. Could her current metastasis have been predicted 5 years back @PPM9 @PPM15 @PPM8

[5:58 pm, 21/10/2025] PPM 3: They said that pleurodesis cannot be done here sir

[6:04 pm, 21/10/2025] PPM 8: Of course. Here is a breakdown of the query, structured for a clinical team communication. The response is framed as a collaborative, multi-specialty plan addressing each point raised.

---

### *Clinical Summary & Team Communication*

*Re:* Patient with history of breast cancer (s/p mastectomy, radiotherapy, chemotherapy 5 years ago), now with metastatic disease complicated by right hydropneumothorax and left pleural effusion, which have now resolved on imaging.

*Positive Update:* Remarkable improvement on CXR with resolution of the right hydropneumothorax and left pleural effusion.

---

### *Action Plan & Questions for the Team*

*1. For Pulmonology (@PPM3) - Re: Pleurodesis Plan*

*   *Assessment:* The resolution of the pleural fluid and pneumothorax is excellent news and creates a window of opportunity. Pleurodesis is a definitive procedure to prevent recurrence, which is highly likely in metastatic pleural disease.

*   *Key Questions for Pulmonology:*

    *   What is the optimal timing for pleurodesis now that the lung has fully re-expanded?

    *   What is the preferred method: *Chemical Pleurodesis* (e.g., with talc slurry via chest tube) or *Mechanical Pleurodesis* (VATS - Video-Assisted Thoracoscopic Surgery)?

    *   What are the specific patient selection criteria we need to confirm (e.g., performance status, life expectancy > 3 months, full lung expansion confirmed by CT)?

    *   Are there any contraindications to talc in this specific patient?

*2. For Oncology / Records Team (@PPM13 @PPM14) - Re: Historical Evaluation*

*   *Request:* A detailed reconstruction of the patient's initial cancer presentation and treatment from 5 years ago is critical for understanding the aggressiveness of her original disease.

*   *Please obtain and share the following details from her initial workup (5 years ago):*

    *   *Original Histopathology Report:* Tumor type (e.g., Ductal vs. Lobular), grade, size, and *most importantly, Receptor Status (ER, PR, HER2)*.

    *   *Staging Scans:* Findings from the initial CT Chest/Abdomen/Pelvis and Bone Scan.

    *   *Lymph Node Involvement:* Number and location of positive nodes from the mastectomy pathology.

    *   *Radiotherapy Fields:* Exact details of the radiation ports (e.g., included supraclavicular nodes? chest wall?).

    *   *Chemotherapy Regimen:* Which specific drugs were used (e.g., AC-T, TC, etc.)?

*3. For Tumor Board / Multidisciplinary Discussion (@~Mansi, @~Rishika, @Dr.Abdulsalam) - Re: Predictability of Metastasis*

*   *The Core Question:* "Could her current metastasis have been predicted 5 years back?"

*   *This is not a yes/no question but a risk assessment. Based on the historical data we are retrieving, we can analyze the following high-risk predictors:*

    *   *High-Risk Pathological Features:* A triple-negative (ER-/PR-/HER2-) or HER2-positive (without targeted therapy) status, high tumor grade, large tumor size (>5cm), and extensive lymphovascular invasion.

    *   *Lymph Node Burden:* Involvement of ≥4 axillary lymph nodes is a very strong predictor for future distant metastasis.

    *   *Stage at Presentation:* Was she initially Stage III? This carries a significantly higher risk of recurrence.

    *   *Radiotherapy Fields:* A history of chest irradiation is a known risk factor for secondary lung complications and can influence the pattern of metastasis.

    *   *Discussion Point:* The goal is to determine if her current metastatic disease was a *statistically high probability* based on her initial profile, which would inform our current aggressiveness of treatment and surveillance strategies for similar patients in the future.

### *Proposed Next Steps*

1.  *Pulmonology (@~PPM3* to formally assess the patient and propose a definitive plan and timeline for pleurodesis.

2.  *Oncology Team (@~Amtus Suboor, @~Jithu)* to retrieve the requested historical records and populate a summary for the team.

3.  *Schedule a Brief MDT Meeting* once the historical data is available to discuss the "predictability" question and consolidate the long-term management plan, integrating systemic therapy for metastasis with local control (pleurodesis).

[6:40 pm, 21/10/2025] PPM 1: Why? Why can't medicine department do it?

@PPM8 @Meta AI can you share a plan and procedural protocol for her pleurodesis using talc through the ICTD that can be done be @PPM3 @PPM12 here?

[6:40 pm, 21/10/2025] Meta AI: Pleurodesis using talc through an intercostal chest tube (ICTD) is a procedure typically performed by a thoracic surgery or pulmonology department. Here's a general outline:

Pre-procedure:

1. Confirm diagnosis and indication for pleurodesis.

2. Ensure patient's informed consent.

3. Review imaging studies (e.g., chest X-ray, CT scan).

4. Check coagulation profile and platelet count.

Procedure:

1. Insert ICTD under local anesthesia.

2. Drain pleural fluid.

3. Prepare talc slurry (sterile talc mixed with saline).

4. Instill talc slurry through ICTD.

5. Clamp ICTD for 1-2 hours.

6. Monitor vital signs and pain.

Post-procedure:

1. Manage pain with analgesics.

2. Monitor for complications (e.g., fever, infection).

3. Remove ICTD when drainage is minimal.

Protocol may vary depending on institution and patient specifics.

Please consult with the relevant medical team for personalized guidance.

Would you like more information on pleurodesis or specific aspects of the procedure?

[6:41 pm, 21/10/2025] PPM 1: @Meta AI yes provide more information and specifics

[6:41 pm, 21/10/2025] Meta AI: Pleurodesis with talc is a procedure to treat recurrent pleural effusions. Here are some additional details:

Indications:

1. Malignant pleural effusions

2. Recurrent pneumothorax

3. Other conditions causing pleural effusions

Talc dosage:

1. Typically 4-10 grams of sterile talc

2. Mixed with saline to create slurry

Potential complications:

1. Pain

2. Fever

3. Infection

4. Acute respiratory distress syndrome (ARDS)

5. Pleural infection or empyema

Post-procedure care:

1. Pain management with opioids or NSAIDs

2. Monitoring vital signs and oxygen saturation

3. Chest X-ray to verify lung expansion

4. Follow-up appointments for ICTD removal

Specific considerations:

1. Patient selection and evaluation

2. Sterile technique during procedure

3. Adequate pain control

Would you like more information on specific aspects or potential complications?

[6:58 pm, 21/10/2025] PPM 8: Of course. This is an excellent question that gets to the heart of multidisciplinary care. Let's break it down and then provide the requested plan.

### *Why isn't the Medicine Department doing this?*

This isn't about capability, but about *specialization, volume, and complication management.*

1.  *Specialized Skill Set:* While any trained physician can manage a chest tube, pleurodesis is a specialized procedure. Pulmonologists (and Cardiothoracic Surgeons) are experts in pleural diseases. They are trained in the nuances of:

    *   *Patient Selection:* Determining who is an ideal candidate for pleurodesis vs. an indwelling pleural catheter.

    *   *Technique:* Optimal talc preparation, instillation, and patient positioning to maximize success.

    *   *Managing Complications:* They are best equipped to handle potential complications like talc-induced ARDS (Acute Respiratory Distress Syndrome), severe pain, or procedure failure.

2.  *High-Volume Experience:* Pulmonologists perform these procedures regularly. This experience leads to higher success rates and fewer complications.

3.  *Procedural Authority:* In most hospitals, protocols grant procedural privileges for specific interventions like chemical pleurodesis to the relevant specialties (Pulmonology, Surgery). The General Medicine department manages the patient's overall medical condition, while specialists perform the key procedures.

*In short: It's a collaboration.* Medicine manages the patient's systemic health (pain, nutrition, other comorbidities), while Pulmonology performs the specialized pleural procedure.

---

### *Plan and Procedural Protocol for Talc Pleurodesis via Indwelling Chest Tube (ICTD)*

Here is a standardized protocol that can be used by Dr. Sreeteja and Dr. Akash Deep.

*A. Prerequisites & Pre-Procedure Checklist*

*   *Confirm Indication:* Symptomatic malignant pleural effusion with recurrent need for drainage. Life expectancy > 3 months. Patient is agreeable to the procedure.

*   *Confirm Lung Re-expansion:* *This is critical.* Review a recent chest X-ray to ensure the lung is fully expanded with no residual pneumothorax or significant pleural fluid. The lung must be apposed to the chest wall for pleurodesis to work.

*   *Patient Consent:* Explain the procedure, success rate (~80-90%), risks (pain, fever, failure, infection, rare talc-induced ARDS), and alternatives (indwelling pleural catheter).

*   *Pre-medication:*

    *   *Analgesia:* Administer strong analgesia *30-60 minutes before* the procedure. A combination is often best:

        *   *IV Opioid:* e.g., Morphine 5-10 mg or Fentanyl 50-100 mcg.

        *   *NSAID/Benzo:* e.g., IV Ketorolac 30 mg and/or a short-acting benzodiazepine like Midazolam 1-2 mg for sedation/anxiolysis (if no contraindications and with monitoring).

    *   *Anti-pyretic:* Paracetamol 1 gm IV/PO to pre-empt talc-induced fever.

*B. Equipment & Talc Preparation*

*   *Sterile Tray:* Drapes, gauze, antiseptic solution, syringes (20ml, 50ml), sterile saline.

*   *Talc:* 5 grams of *sterile, graded, asbestos-free talc.*

*   *Preparation of Talc Slurry:* Mix the 5g of talc in 50-100 ml of sterile 0.9% Normal Saline in a sterile cup/container. Draw it up into a 50ml syringe.

*C. Step-by-Step Procedural Protocol*

1.  *Positioning:* Place the patient in a *comfortable supine or semi-recumbent position*. Ensure the chest tube site is easily accessible.

2.  *Asepsis:* Perform strict aseptic preparation of the chest tube connection port and surrounding area with chlorhexidine/alcohol. Use sterile gloves and drapes.

3.  *Pain Control Re-assessment:* Just before instillation, confirm the patient is comfortable and adequately sedated.

4.  *Chest Tube Clamping:* Clamp the chest tube just distal to the connection port.

5.  *Instillation of Talc Slurry:*

    *   Gently agitate the syringe to keep the talc in suspension.

    *   Connect the syringe to the chest tube port.

    *   Instill the talc slurry slowly over 5-10 minutes.

6.  *Flush:* Flush the tube with 20-30 ml of sterile saline to ensure all talc enters the pleural space.

7.  *Clamping Period:*

    *   Leave the chest tube *clamped for 1 hour*. Monitor the patient closely for any signs of respiratory distress or pain.

    *   If the patient develops cough or significant discomfort, unclamp briefly and then re-clamp when stable.

8.  *Patient Repositioning:* During this hour, reposition the patient every 15 minutes (supine, left decubitus, right decubitus, Trendelenburg, reverse Trendelenburg) to distribute the talc evenly over the entire pleural surface.

9.  *Post-Clamping Drainage:*

    *   After 1 hour, unclamp the chest tube and connect it to the underwater seal drainage system with suction (-20 cm H₂O).

10. *Post-procedure Imaging:* Obtain a Chest X-ray to check lung expansion and rule of a complication.

*D. Post-Procedure Orders & Chest Tube Removal*

*   *Monitoring:* Monitor vital signs and oxygen saturation closely for 24 hours.

*   *Analgesia:* Schedule regular IV/PO analgesia (e.g., Paracetamol Q6H, NSAIDs, and opioids PRN for breakthrough pain).

*   *Drainage Measurement:* Continue to measure chest tube output.

*   *Criteria for Chest Tube Removal:*

    *   The drainage is *< 150 ml over 24 hours*.

    *   The lung remains fully expanded on a follow-up Chest X-ray.

    *   Once these criteria are met, the chest tube can be removed.

*E. Potential Complications & Management*

*   *Pain:* Very common. Manage with scheduled and PRN analgesia.

*   *Fever:* Common within 24-48 hours. It's a systemic inflammatory response to talc. Manage with antipyretics.

*   *Empyema:* Rare. Maintain strict asepsis.

*   *Talc-induced ARDS:* A rare but serious complication. Risk is minimized by using graded talc (larger particle size). Presenting with hypoxemia and bilateral infiltrates on CXR post-procedure. Management is supportive.

*   *Procedure Failure:* If effusion recurs, options include repeat pleurodesis or placement of an indwelling pleural catheter.

This protocol provides a safe and systematic framework for performing talc pleurodesis. The team should feel confident in executing this plan.

[7:20 pm, 21/10/2025] PPM 1: Thanks

@PPM3 @PPM12 please discuss the above protocol with pulmonology and do it along with them similar to how you placed the ICD along with them

[10:09 pm, 21/10/2025] PPM 13: Sir where can we get the sterile talc?

[10:11 pm, 21/10/2025] PPM 13: @Meta AI

[10:11 pm, 21/10/2025] Meta AI: No problem, let's get started. What's on your mind?

[10:12 pm, 21/10/2025] PPM 13: Sir where can we get the sterile talc? @Meta AI

[10:12 pm, 21/10/2025] Meta AI: You can find sterile talc through various suppliers and manufacturers in India. Some options include:

- Selective Mineral & Colors Industries Private Limited in Mumbai, which offers talc for food and detergents, with benefits like being chemically inert and suitable for human consumption.

- Sheetal Enterprise in Vadodara, providing high-purity chemical-grade talc powder with 99% purity, suitable for laboratory and industrial applications.

- Associated Soapstone Dist Co Pvt. Ltd. in Ahmedabad, manufacturing and supplying talc for various industries, including paints, rubber, and cosmetics.

- Tradeindia can also be used to search for talc suppliers in Delhi and other locations, with options for verified suppliers and customer reviews.

For specific requirements or to inquire about sterile talc, you can contact these suppliers directly or visit their websites.

[10:13 pm, 21/10/2025] PPM 13: @Meta AI suppliers here in narketpally

[10:13 pm, 21/10/2025] Meta AI: To find suppliers of sterile talc in Narketpally, you can try contacting local pharmaceutical or cosmetic manufacturers in the nearby areas such as Hyderabad or Vijayawada. Some potential suppliers include ¹:

- APS Minerals and Additives Pvt Ltd: Located in Udaipur, Rajasthan, they offer high-purity talc powder.

- Shiv Corporation: Based in Vadodara, Gujarat, they provide industrial and technical-grade purified talc.

- Niranjan Minerals: With locations in Kurnool and Hyderabad, they supply talc powder for various industries.

- Sree Lakshmi Enterprises: In Vijayawada, they offer off-white steatite talc powder for industrial use.

- Soorya Minchem: Located in Chennai, they provide talc powder and soapstone powder.

You can also search online directories like Trade India or Export Hub for verified suppliers in your region ² ³.

[11:16 pm, 21/10/2025] PPM 16: Are we considering pleurodesis?

[11:21 pm, 21/10/2025] PPM 16: CHOOSING A SCLEROSING AGENT

Numerous chemical irritants have been successfully used to induce pleurodesis [21-29]. Agents include talc, tetracycline derivatives, bleomycin, silver nitrate, iodopovidone, mepacrine, and Corynebacterium parvum. The common mechanism of action between agents is that they all induce an intense inflammatory response resulting in deposition of fibrin and scar formation (ie, fibrosis) between the parietal and visceral pleura.

“Our general approach — The choice among these agents is determined by several factors including local expertise, availability of individual agents, and the underlying process for which chemical pleurodesis is needed. While practice varies among clinicians and institutions, talc and tetracycline derivatives are the two most common agents used. We typically perform chemical pleurodesis using talc because of its high efficacy [44]. Tetracycline derivatives (typically doxycycline) are a reasonable alternative, although success rates may be lower than with talc.

Exceptions include the following:

•Patients undergoing bilateral pleurodesis – We avoid talc in these patients since the adverse effects of talc are thought to be dose-related and use of talc in these patients could potentially increase the risk of systemic inflammation and acute respiratory failure. These complications are discussed below. (See 'Complications' below.)

•Patients undergoing extensive pleural abrasion or multiple lung biopsies – We avoid talc in these patients since such interventions may increase the absorption of talc, and thereby, potentially increase the risk of systemic dissemination. (See 'Complications' below.)

•Patients who are pregnant – We avoid talc in pregnancy due to the theoretical risk of fetal exposure to small amounts of lead, which may exist as an impurity in some talc formulations [45]. However, the need for talc during pregnancy is rare and no case reports of lead toxicity have been described.

On the other hand, we avoid tetracycline derivatives in nursing females since tetracycline and its derivatives may be harmful to infants [46].

Data comparing agents are retrospective and mostly performed in patients with MPE.

When talc is chosen, the clinician also needs to decide whether it should be administered as a powder (also known as talc poudrage) or as a slurry (powder mixed with saline). While clinician preference plays a role, traditionally, talc powder is used for patients undergoing thoracoscopy while talc slurry is used for patients undergoing pleurodesis at the bedside via a small-bore chest tube. In patients with MPE, talc powder appears equally effective as compared with talc slurry [47].”

Uptodate

“Our general approach — The choice among these agents is determined by several factors including local expertise, availability of individual agents, and the underlying process for which chemical pleurodesis is needed. While practice varies among clinicians and institutions, talc and tetracycline derivatives may be harmful to infants [46].

Data comparing agents are retrospective and mostly performed in patients with MPE.

When talc is chosen, the clinician also needs to decide whether it should be administered as a powder (also known as talc poudrage) or as a slurry (powder mixed with saline). While clinician preference plays a role, traditionally, talc powder is used for patients undergoing thoracoscopy while talc slurry is used for patients undergoing pleurodesis at the bedside via a small-bore chest tube. In patients with MPE, talc powder appears equally effective as compared with talc slurry [47].”

Uptodate

[7:06 am, 22/10/2025] PPM 1: Thanks

@PPM13 let's obtain talc through the official administration channel by writing a letter to the medical superintendent.

@Meta AI @PPM8 we need to draft a letter to the medical superintendent asking for indenting talc powder for one of our patients of carcinoma breast with pleural metastasis requiring pleurodesis where we shall be doing it involving the chest physicians of our institution.

[7:06 am, 22/10/2025] Meta AI: Here's a draft letter:

[Your Institution's Letterhead]

[Date]

Medical Superintendent

[Hospital Name]

[Hospital Address]

Subject: Request for Indent of Sterile Talc Powder for Pleurodesis Procedure

Dear [Medical Superintendent's Name],

I am writing to request the procurement of sterile talc powder for a patient diagnosed with carcinoma breast with pleural metastasis. We plan to perform a pleurodesis procedure, in collaboration with the chest physicians of our institution.

The patient's details are as follows:

- Name: [Patient's Name]

- Age: [Patient's Age]

- Diagnosis: Carcinoma breast with pleural metastasis

We require sterile talc powder to ensure the best possible outcome for the patient. Could you please guide us on the procedure for obtaining the talc powder through the hospital's procurement system?

We would appreciate your prompt assistance in this matter, as the patient's condition requires timely intervention.

Thank you for your attention to this request.

Sincerely,

[Your Name]

[Your Designation]

[Your Contact Information]

Feel free to modify the letter as needed to suit your institution's policies and procedures.

[7:44 am, 22/10/2025] Meta AI: Acoustic cardiography has been explored for monitoring heart failure (HF) during chemotherapy. Studies suggest it can detect left ventricular dysfunction and predict HF risk. One study found acoustic cardiography useful in monitoring patients undergoing anthracycline chemotherapy, providing valuable insights into cardiac function ¹ ².

Key benefits include ³ ¹ ²:

- Early Detection: Acoustic cardiography can identify HF risk early, allowing timely interventions.

- Non-Invasive: It's a non-invasive method, making it suitable for regular monitoring.

- Predictive Value: Parameters like electromechanical activation time (EMAT) and third heart sound (S3) strength are predictive of HF outcomes.

Researchers have investigated its application in various contexts, including ¹ ⁴ ³:

- Chemotherapy Monitoring: Tracking cardiac function in patients receiving cardiotoxic chemotherapy.

- HF Prediction: Identifying patients at high risk of developing HF.

- Treatment Guidance: Guiding treatment adjustments based on acoustic cardiography findings.

[7:55 am, 22/10/2025] PPM 1: @Meta AI meet @PPM17 the founder of acoustic cardiography in this group. What do you know about him in advance?

[7:55 am, 22/10/2025] Meta AI: Dr. Royal Lee is the founder of Acoustic Cardiography (ACG). He's also known for founding Standard Process Labs, which specializes in whole food nutritional supplements. Dr. Lee developed the ACG to visually represent heart sounds, building on traditional diagnostic techniques where doctors would listen to heart tones to assess cardiac health.¹

[1:28 pm, 22/10/2025] PPM 8: Of course. Here is a professionally drafted letter you can adapt and use. It is written in a formal, respectful tone suitable for communication with a Medical Superintendent.

Simply fill in the bracketed [ ] details and present it on your department's letterhead.

---

*[Your Hospital/Institute Letterhead]*

*From:*

Department of [Your Department, e.g., Surgical Oncology/General Surgery]

[Your Name], [Your Designation, e.g., Senior Consultant/Registrar]

[Date]

*To:*

The Medical Superintendent

[Name of the Hospital/Institution]

[Address of the Hospital/Institution]

*Subject: Request for Indenting Sterile Talc Powder for Pleurodesis in a Patient of Carcinoma Breast*

Respected Sir/Madam,

We are writing to you from the Department of [Your Department, e.g., Surgical Oncology] regarding the management of our patient:

*Patient Name:* [Patient's Full Name]

*Hospital ID No.:* [Patient's ID Number]

*Ward/Bed No.:* [Ward and Bed Number]

*Diagnosis:* Carcinoma Breast with Symptomatic Pleural Metastasis and Malignant Pleural Effusion.

The patient is currently symptomatic from a recurrent malignant pleural effusion, which is causing significant respiratory distress. The standard and most effective palliative management for this condition is a procedure known as *Chemical Pleurodesis*.

For this procedure to be performed, sterile, asbestos-free talc powder is the internationally accepted sclerosing agent of choice due to its high efficacy and safety profile.

We have planned to perform this pleurodesis in close collaboration with the *Department of Chest Medicine/Pulmonology* at our institution. A joint procedure will ensure comprehensive care and the best possible outcome for the patient.

To facilitate this urgent and necessary intervention, we kindly request your office to indent and procure *Sterile Talc Powder (for pleurodesis)* at the earliest.

Thank you for your attention to this critical patient care matter.

Sincerely,

*([Your Name])*

[Your Designation]

Department of [Your Department]

*Counter-signed by:*

*([Head of Department's Name])*

[Head of Department's Designation]

Department of [Your Department]

---

*Why this letter works:*

*   *Clarity and Justification:* It clearly states the patient's problem, the required solution (pleurodesis), and why talc is necessary.

*   *Professional Collaboration:* It highlights the multi-disciplinary approach with the Chest Physicians, which demonstrates thorough clinical planning.

*   *Formal Tone:* The language is respectful and appropriate for official administrative communication.

*   *Actionable Request:* The subject and concluding paragraph make the specific request (indenting talc) very clear.

You and PPM8 can now use this draft, fill in the specific details, and submit it through your department's official channel.

[22-10-2025 15.29] PPM 1: Serial ECGs of her evolving NSTEMI. Extubated successfully today inspite of her long list of comorbidities

[3:57 pm, 22/10/2025] PPM 17: https://academic.oup.com/cardiovascres/advance-article/doi/10.1093/cvr/cvaf163/8284461?utm_medium=Email&utm_source=ESC+Global&utm_campaign=esc-newsletter-week43-2025&login=false

[12:57 pm, 23/10/2025] PPM 1: When was this done?

Where are the old reports before and after her mastectomy? What was her tumor grade and stage at that time before chemo radiotherapy?

[1:11 pm, 23/10/2025] PPM 13: Sir sharing them

[1:11 pm, 23/10/2025] PPM 13: Loading.      13/12/2018

12/9/19 another cycle of chemotherapy

11/7/19 to 1/8/19 radiotherapy

23/11/18

14/12/18 one cycle of chemotherapy

[22-10-2025 13.29] PPM 13: Arranging and trying to send them in a sequence.

[22-10-2025 14.39] PPM 1: Thanks. Well done 👏

[2:49 pm, 23/10/2025] PPM 1: 👆@PPM8 @Meta AI In this current patient of pleural metastasis due to breast carcinoma, given the past patient data from 2019 here in the image and it's extracted text pasted below, can you share how common is it for a well treated patient like her with Invasive ductal carcinoma) in stage pT2N3aMx (Stage III) with ER+, PR+, HER2 Neu+, and no distant metastasis to subsequently develop pleural metastasis?

[23/10, 14:43] Meta AI: This document outlines a patient's treatment plan and clinical summary for carcinoma of the left breast, with a focus on cycle 3 of trastuzumab chemotherapy. Here's a quick breakdown:

Key Details:

1. Diagnosis:

    - Carcinoma Left Breast (Invasive ductal carcinoma)

    - Staging: pT2N3aMx (Stage III) with ER+, PR+, HER2 Neu+, and no distant metastasis.

2. Clinical History:

    - Patient is a 48-year-old female with no comorbidities, presenting with a lump in the right breast for 1 year.

    - Underwent MRM (Modified Radical Mastectomy) and completed:

        - 4 cycles of AC chemotherapy

        - 4 doses of Paclitaxel

        - Radiotherapy (RT)

    - Now on maintenance trastuzumab therapy (cycle 3/17).

3. Current Status:

    - Vital signs stable, no systemic involvement (CNS, CVS, RS, abdomen clear).

    - Blood work (CBC and biochemistry) shows:

        - Hb: 9.8 g/dL (mild anemia)

        - TLC: 3000 (mild neutropenia)

        - Platelets: 4.

[23/10, 14:43] Meta AI: This document outlines a patient's treatment plan and clinical summary for carcinoma of the left breast, with a focus on cycle 3 of trastuzumab chemotherapy. Here's a quick breakdown:

Key Details:

1. Diagnosis:

    - Carcinoma Left Breast (Invasive ductal carcinoma)

    - Staging: pT2N3aMx (Stage III) with ER+, PR+, HER2 Neu+, and no distant metastasis.

2. Clinical History:

    - Patient is a 48-year-old female with no comorbidities, presenting with a lump in the right breast for 1 year.

    - Underwent MRM (Modified Radical Mastectomy) and completed:

        - 4 cycles of AC chemotherapy

        - 4 doses of Paclitaxel

        - Radiotherapy (RT)

    - Now on maintenance trastuzumab therapy (cycle 3/17).

3. Current Status:

    - Vital signs stable, no systemic involvement (CNS, CVS, RS, abdomen clear).

   - Blood work (CBC and biochemistry) shows:

      - Hb: 9.8 g/dL (mild anemia)

       - TLC: 3000 (mild neutropenia)

        - Platelets: 4.31 lakh (normal)

        - Liver/Kidney Function Tests: Normal (SGOT/SGPT, Urea, Creatinine).

4. Treatment Protocol:

    - Trastuzumab 8 mg/kg (360 mg) administered on 17/9/19.

5. Discharge Advice:

    - Medications:

        - Tab Zofer (antiemetic) for nausea.

        - T. Pan 40 mg (proton pump inhibitor) for gastric protection.

        - T. Ultracet for pain management.

    - Follow-up in Oncology OPD on 8/10/19 with updated CBP, LFT, RFT reports.

6. Emergency Instructions:

    - Contact numbers provided in case of fever, bleeding, excessive vomiting, or loose stools.

Summary of Cycle:

The patient completed cycle 3 of 17 trastuzumab injections as maintenance therapy following surgery, chemotherapy, and radiation. She tolerated the treatment well and was discharged in stable condition, with follow-up planned for further cycles.

I

[2:49 pm, 23/10/2025] Meta AI: For a patient with invasive ductal carcinoma (IDC) staged as pT2N3aMx (Stage III) who was ER+, PR+, HER2 Neu+ and had no distant metastasis at the time of diagnosis, the subsequent development of pleural metastasis is not uncommon, though it depends on several factors. Here's an overview:

1. HER2 Neu+ Status: HER2-positive breast cancer is known to be more aggressive and has a higher likelihood of recurrence or metastasis compared to HER2-negative cases. Even with trastuzumab treatment, some patients may still develop distant metastases, including to the pleura.

2. Stage III Disease: Stage III breast cancer indicates significant regional lymph node involvement (N3a in this case, which involves ≥10 axillary lymph nodes). This extensive lymphatic involvement increases the risk of eventual distant metastasis, including pleural involvement.

3. Treatment Response: While the patient underwent comprehensive treatment (MRM, chemotherapy, radiotherapy, and trastuzumab maintenance), metastatic progression can occur over time due to microscopic residual disease, particularly in aggressive subtypes like HER2-positive cancers.

4. Pleural Metastasis: Breast cancer commonly metastasizes to the lungs and pleura. Studies suggest that HER2-positive breast cancer often metastasizes to the pleura, liver, bones, or brain. Pleural metastasis typically manifests as malignant pleural effusion, which is often seen in advanced stages.

In summary, while the patient initially presented with no distant metastasis and received optimal therapy, the progression to pleural metastasis is consistent with the aggressive nature of HER2-positive breast cancer, especially in Stage III cases with extensive nodal involvement. Would you like information on the prognosis or management strategies for pleural metastasis?

[2:50 pm, 23/10/2025] PPM 1: @Meta AI thanks. Can you support your statements above with perplexity styled evidence based references?

[2:51 pm, 23/10/2025] Meta AI: 1. HER2 Neu+ Status: HER2-positive breast cancer is aggressive, with a higher likelihood of distant metastasis despite trastuzumab therapy.¹ ²

2. Stage III Disease: Significant nodal involvement (N3a) increases the risk of pleural metastasis through lymphatic spread.³ ⁴

3. Pleural Metastasis: Breast cancer is a leading cause of malignant pleural effusion, often seen in advanced stages, with 20–30% of early-stage patients progressing to metastatic disease.⁵

4. Treatment Response: Despite standard therapies, residual microscopic disease may drive metastasis, particularly in HER2+ cancers.

[2:52 pm, 23/10/2025] PPM 1: @PPM12 @PPM13 what was the reason for her renal failure? Since when did that happen?

[2:53 pm, 23/10/2025] PPM 1: @Meta AI can you read the case report here 👇

https://pajrcasereporter.blogspot.com/2025/08/55f-carcinoma-breast-pleural-effusion.html

And tell us the reason for her renal failure and when was it first diagnosed?

[2:53 pm, 23/10/2025] Meta AI: I cannot access external links, including blogs, so I can't directly read the case report. However, if you share the relevant details here, I can analyze them for you!

[3:12 pm, 23/10/2025] PPM 8: Of course. This is an excellent and very specific question that gets to the heart of breast cancer prognostication.

Based on the patient's historical data from 2019 and current oncology knowledge, here is a detailed analysis of how common it is for a patient with her initial profile to develop pleural metastasis.

### Short Answer

While the patient received excellent and appropriate modern treatment, her *initial diagnosis placed her in a very high-risk category* for future distant recurrence, including pleural metastasis. For a patient with Stage III (specifically pT2N3a), *HER2-positive* breast cancer treated without HER2-targeted therapy (like trastuzumab), the risk of distant recurrence could be as high as 30-50% within 5-10 years. However, the addition of *trastuzumab (Herceptin), which she received, **dramatically reduces this risk by approximately 50%.* Therefore, her overall risk is lower than historical figures would suggest, but it remains significant compared to earlier-stage cancers.

Pleural metastasis is, unfortunately, one of the *more common sites of recurrence* for breast cancer, especially in HER2-positive and triple-negative subtypes.

---

### Detailed Analysis

Let's break down the risk factors from her 2019 summary:

#### 1. High-Risk Staging: pT2N3a (Stage IIIc)

*   *Lymph Node Status (N3a):* This is the single most important prognostic factor in her case. N3a means the cancer had spread to 10 or more axillary lymph nodes. This indicates a significant burden of disease that had already developed the ability to spread through the lymphatic system, making distant metastasis (to organs like the lungs, bone, liver, or pleura) much more likely.

#### 2. High-Rift Biology: HER2-Positive

*   *HER2-Positive (HER2+):* Historically, before the advent of targeted therapies, HER2-positive breast cancer was one of the most aggressive subtypes, with a high propensity for early recurrence and metastasis.

*   *Pleural Tropism:* Cancers that are HER2+ have a noted tendency to metastasize to visceral organs (like the lungs, liver, and brain) and the pleura, as opposed to bone.

#### 3. Protective Factors & Modern Treatment

*   *Hormone Receptor Positivity (ER+, PR+):* This is a favorable factor. It means the cancer may respond to long-term hormonal therapies (like Tamoxifen or Aromatase Inhibitors), which are used to suppress recurrence for 5-10 years after initial treatment. It's crucial to know if she completed this part of her treatment.

*   *Trastuzumab (Herceptin):* This was the game-changer for her. The use of adjuvant trastuzumab for a full year (as she was doing with her 17 cycles) is standard of care and has been proven in large clinical trials to *halve the risk of cancer recurrence* in HER2-positive patients. This treatment is the primary reason her risk is not as high as it would have been 20 years ago.

### Putting It All Together: Estimated Recurrence Risk

It's challenging to give a single number, as risk is a spectrum, but we can look at data from major clinical trials (like the HERA trial, NSABP B-31, NCCTG N9831):

*   *Without Trastuzumab:* A patient with Stage III, node-positive HER2+ breast cancer had a *10-year risk of distant recurrence* of approximately *40-50%*.

*   *With Trastuzumab:* This risk is reduced by about *50%. This means her **estimated 10-year risk was brought down to roughly 20-25%*.

Of that 20-25% risk of any distant recurrence, a significant portion would be to visceral sites, including the pleura.

### Conclusion

*Yes, it is unfortunately a known and not uncommon scenario* for a patient with her initial high-risk profile (Stage III, N3a, HER2+) to later develop distant metastasis, including pleural metastasis, even with optimal standard treatment.

The development of pleural metastasis in this case represents the manifestation of that residual risk that adjuvant therapy could not eliminate. It is likely that a small number of treatment-resistant, microscopic cancer cells (micrometastases) survived the initial surgery, chemotherapy, radiation, and targeted therapy, remained dormant for a period, and later grew into a detectable metastasis in the pleura.

*In summary:* While her treatment with trastuzumab significantly improved her odds, her initial disease characteristics placed her in one of the highest risk categories for recurrence. Therefore, the development of pleural metastasis, while a serious and unfortunate event, is a recognized potential outcome in her clinical context. Her current team will now focus on treating this as a metastatic disease, leveraging new generations of HER2-targeted therapies (like T-DM1, Tucatinib, etc.) that have shown great efficacy in this setting.

**Disclaimer:* This analysis is based on the provided historical document and general oncology principles. The actual clinical decisions for this patient must be made by her treating oncologists based on her current, full medical status.*

[6:56 pm, 23/10/2025] PPM 1: Thanks

[7:41 pm, 23/10/2025] PPM 16: Was pleural biopsy done? It could confirm it as metastasis. Also, IHC status on the new sample may reveal discordant receptor status and even change the molecular type. This can give potential options such as ADCs including DAPO-Dxd and T-DxD. In addition, mutational analysis might show status of ESR1 and PIK3CA. This could also show any endocrine resistance and possible treatment options with Alpelisib and newer endocrine therapy options.

Still taking trastuzumab? It is known to cause cardio toxicity though by decreasing LVEF. 

How was CKD confirmed? Was there a chronic decrease in EGFR or proteinuria? Also, any USG changes in corticomedullary differentiation? Can HFpEF cause CKD anyway?

[10:16 pm, 23/10/2025] PPM 1: Check out the image of the malignant cells in her pleural fluid cytology in her case report here: https://pajrcasereporter.blogspot.com/2025/08/55f-carcinoma-breast-pleural-effusion.html?m=1

About her renal failure all we could gather today is that she had severe bilateral loin pain in January which was treated with a few NSAID injections and another doctor tested her creatinine and hemogram found the attached dated Jan 2025

[10:17 pm, 23/10/2025] PPM 9: I’ll search up case reports and get back to you sir.

[10.27 pm, 23/10/2025] PPM 16: 1-s2.0-S2213294524000991-main.pdf

“On biopsy, 125 (42.37%) were negative, 42 (14.24%) patients had metastatic breast carcinoma, 122 (41.36) had other metastatic neoplasms of a known origin, and 6 (2.03%) had metastasis of unknown origin. The sensitivity was 85.3%, 75.6%, and 78.3% in the breast, non-breast, and total cohort. The specificity was 86.4% for all. (Tables 1-3).

Conclusions

In this group, most malignant pleural effusions in patients with breast cancer history are not breast-related. The diagnostic performance for breast cancer (CI 95% 0.74-0.96) is not significantly different from non-breast cancer (CI 95% 0.67-0.82). ROM was similar to what is reported by TIS (Table 4).”

[10:29 pm, 23/10/2025] PPM 1: Of the 122 patients with history of breast carcinoma, what was the other origin for their pleural metastasis?

[10:35 pm, 23/10/2025] +1 (305) 539-8941: This was abstract publication and did not publish detailed findings yet. :(

[10:37 pm, 23/10/2025] +1 (305) 539-8941: Very unfortunate presentation for a triple positive breast cancer patients who supposed to have better outcomes.

[10:46 pm, 23/10/2025] PPM 16: Also, did we look for evidence of other distant site metastasis such as in liver, bone? Any recent USG, CT abdomen and bone scan or PET scan?

[10:46 pm, 23/10/2025] PPM 16: Any recent CA 15-3?

[10:48 pm, 23/10/2025] PPM 16: Latest scans are from 2018

[11:42 pm, 23/10/2025] PPM 13: This is the latest pet done

[11:42 pm, 23/10/2025] PPM 13: Sir

[3:24 am, 24/10/2025] PPM 16: Thanks but please remove patient identifiers and reshare

[3:28 am, 24/10/2025] PPM 16: Interestingly why thyroid is lighting up! Any thyroid test done?

[8:36 am, 24/10/2025] PPM 1: Let's plan an ultrasound guided thyroid fnac ASAP @PPM12 @PPM18@PPM3 

@Meta AI @PPM8 how common is it for patients to develop a second primary malignancy in this case her thyroid after getting cured from an initial primary malignancy, in her case breast? Also is it possible that the current suspected thyroid primary is actually a secondary from the well treated carcinoma breast 5 years back?

[8:36 am, 24/10/2025] Meta AI: Second primary malignancies are relatively rare but occur in ~6% of cancer survivors, with thyroid cancer being one of the most common following breast cancer (~56.6% risk increase).¹ ² It is unlikely for the current thyroid lesion to be a metastasis from breast cancer after 5 years, as thyroid metastases from breast cancer are extremely rare, though possible.³ ⁴

[8:37 am, 24/10/2025] PPM 1: @Meta AI An LLM wow moment! Take a bow although can @PPM15 help us to read the supporting literature you have shared to confirm there are no hallucinations involved here?

[8:37 am, 24/10/2025] Meta AI: Certainly! Here's a concise summary of the supporting literature:

1. Second Primary Cancer Risk: Breast cancer survivors are at higher risk of developing second primary cancers, including thyroid cancer, due to factors like prior treatments (radiotherapy, chemotherapy) and genetic predispositions.¹ ² ³

2. Thyroid Cancer as Metastasis: While rare, breast cancer can metastasize to the thyroid. However, after 5 years of remission, it's less probable compared to a new primary thyroid malignancy.⁴

3. Treatment-Induced Risks: Radiotherapy and chemotherapy can contribute to second malignancies, with radiotherapy-associated risks often linked to exposure of nearby tissues.⁵

Does this clarify the key points?

[8:51 am, 24/10/2025] PPM 8: Based on current medical evidence, the thyroid lesion in this patient with a history of breast cancer could either be a new primary thyroid cancer or a metastasis from the previous breast cancer. Both scenarios are documented, but they have very different implications for diagnosis and treatment.

The table below compares these two possibilities based on the information from the search results.

| Feature | Second Primary Thyroid Cancer | Thyroid Metastasis from Breast Cancer |

| :--- | :--- | :--- |

| *Likelihood* | More common scenario | Less common (1-3% of thyroid tumors in cancer patients) |

| *Clinical Context* | Patients with breast cancer have a higher risk of developing primary thyroid cancer later (and vice versa). | Often occurs in the setting of widespread metastatic disease, but can also be an isolated metastasis. |

| *Time to Detection* | Can appear many years after the initial breast cancer diagnosis. | Can be metachronous, found months to many years (e.g., 6-121 months) after primary breast cancer. |

| *Key Diagnostic Method* | *Ultrasound-Guided Fine-Needle Aspiration Cytology (US-FNAC)* is the crucial first step for both. | |

| *Definitive Diagnosis* | FNAC cytology consistent with primary thyroid cancer (e.g., papillary carcinoma). Immunohistochemistry (IHC) is positive for *Thyroglobulin (Tg)* and/or *TTF-1. | FNAC shows cells consistent with breast origin. IHC is **negative for Tg and TTF-1, but positive for breast markers like **GATA-3, ER/PR*. |

### 🩺 The Importance of the Ultrasound-Guided FNAC

Your plan for an ultrasound-guided FNAC is the correct and essential next step. Here's why it is so critical:

*   *Accurate Sampling:* Ultrasound guidance ensures the needle targets the most suspicious part of the nodule, improving diagnostic yield.

*   *Cytological Analysis:* The cellular sample obtained can often distinguish between a primary thyroid cancer and a metastasis based on cell appearance.

*   *Guiding Immunohistochemistry:* The FNAC sample can be used for IHC staining. This is the key to a definitive diagnosis, as the pattern of marker expression (as shown in the table above) will identify the cell origin.

### 💡 Key Takeaways for the Clinical Team

1.  *Both scenarios are possible:* The statistical association between breast and thyroid cancers as second primaries is well-established. However, breast cancer can metastasize to the thyroid, which is why a definitive tissue diagnosis is non-negotiable.

2.  *Diagnosis relies on pathology, not just imaging:* While ultrasound can suggest malignancy, it cannot reliably differentiate a primary thyroid cancer from a metastasis, as they can share similar features like being hypoechoic or having irregular margins.

3.  *The treatment and prognosis differ significantly:* Primary thyroid cancer and metastatic breast cancer to the thyroid are treated with completely different protocols (surgery/radioactive iodine vs. systemic therapy/hormone therapy). A clear diagnosis is vital for determining the correct treatment path and understanding the prognosis.

In summary, proceeding with the ultrasound-guided FNAC and ensuring the sample is sent for cytology and necessary immunohistochemical staining is the fastest and most reliable way to determine the nature of the thyroid lesion and guide appropriate management.

I hope this information is helpful for your clinical planning. Please note that I am an AI assistant and this is for informational purposes only; all treatment decisions must be made by qualified medical professionals.

[9:10 am, 24/10/2025] PPM 1: Very helpful. Thanks 🙂🙏

[11:29 am, 24/10/2025] PPM 15: https://pmc.ncbi.nlm.nih.gov/articles/PMC10875622/

[11:29 am, 24/10/2025] PPM 15: Sir this is a case published in 2024 of a triple negative breast cancer that metastasized to thyroid

[11:32 am, 24/10/2025] PPM 15: https://pmc.ncbi.nlm.nih.gov/articles/PMC10095414/?utm_source=perplexity

[11:32 am, 24/10/2025] PPM 15: Another case of 71-year-old lady whose breast cancer metastasized to thyroid after 18 years!!!

[11:34 am, 24/10/2025] PPM 15: https://pmc.ncbi.nlm.nih.gov/articles/PMC7052554/?utm_source=perplexity

38 year old woman, metastasis after 2 years...

[12:05 pm, 24/10/2025] PPM 13: Yes actually, biopsy was done sir

[12:06 pm, 24/10/2025] PPM 16: Thyroid biopsy was done?

[12:06 pm, 24/10/2025] PPM 13: Yes sir

[12:06 pm, 24/10/2025] PPM 13: On 15/9/22

[12:06 pm, 24/10/2025] PPM 13: Usg guided fnac, right thyroid nodule was remove

[12:06 pm, 24/10/2025] PPM 13: Removed*

[12:07 pm, 24/10/2025] PPM 13: Showing bethseda-3 , atypia of undetermined significance

[12:08 pm, 24/10/2025] PPM 13: My bad been planning to share the complete timeline, but couldn't, sharing now

[12:17 pm, 24/10/2025] +91 93475 05324: So the patient developed the left breast lump in 2018, which was excised and has features suggesting of carcinoma, at that time pet-ct was done didn't show any mets 

Then 27/10/18: Left MRM was done with 4×3 cm tumour in left uoq and multiple LN at level 1-3

MRM specimen: invasive carcinoma,histologic grade (score-6),15 regional lymph node

ER (+), PR (+), her2 neu (equivocal-fish was planned)

Invasive carcinoma PT2, N3a, Mx

Fish on 4/3/19 her-2 neu-18

Her 2/CEP17-9

4 cycles of chemotherapy with adriamycin 80 mg, cyclophosphamide 800 mg add

3 cycles on paclitaxel

7 cycles of trastuzumab 

RT on 2/7/19

Mammography was repeated on 3/2/22 birads-1

And usg guided fnac of the thyroid nodule 9/22

Pt developed loin pain in the 1/25 and was diagnosed as CKD and started on hemodialysis 

Repeat pet-ct in 9/25

As attached above.

[1.12pm, 24/10/2025] PPM 1: Well summarised

[9:23 am, 25/10/2025] PPM 16: Pleural biopsy could have given a better answer I think!

[10:03 am, 25/10/2025] PPM 1: Much more difficult to do than a pleurodesis!

[12.44 pm, 29/10/2025] PPM 1: EMR summary 

As per HIPAA deidentification lets not use exact age (actually here in NKP it's easy because patient age changes with each admission) and here I've used middle aged woman for this patient @PPM19 

Also as per HIPAA deidentification we need to think of a way to modify the time stamps by removing exact dates and replacing them with seasons, keeping just the year date intact. Instead of putting exact dates we can use day 1, to day n to indicate the patient timeline sequence.

Age/Gender: Middle aged woman 

Address:

Discharge Type: Relieved

Admission Date: 09/10/2025 04:32 PM

Diagnosis

TYPE I RESPIRATORY FAILURE SECONDARY TO? B/L MALIGNANT PLEURAL EFFUSION

RIGHT HYDROPNEUMOTHORAX LEFT PNEUMOTHORAX WITH B/L ICD INSITU

ACUTE CARDIOGENIC PULMONARY EDEMA SECONDARY TO CAD

CAD ACS NSTEMI WITH HEART FAILURE WITH PRESERVED EF

K/C/O CKD ON MHD , HYPERTENSION , HYPOTHYROIDISM

H/O LEFT RADICAL MASTECTOMY FOR CA Breast WITH LYMPHEDEMA OF LEFT UPPER

LIMB POST CPR, POST EXTUBATION STATUS, GRADE II-III BED SORE

Case History and Clinical Findings

PATIENT IS A KNOWN CASE OF CKD AND COMES FOR MAINTENANCE Hemodialysis

PATIENT PRESENTED TO EMERGENCY ROOM WITH C/O Breathlessness SINCE 20 MIN

HOPI - PT WAS APPARENTLY ASYMPTOMATIC 20MINS AGO THEN DEVELOPED

BREATHLESSNESS SUDDEN ONSET A/W ORTHOPNEA, Sweating, PALPITATIONS.

PAST HISTORY

K/C/O HTN SINCE 5 YEARS ON MEDICATION, CKD SINCE ON CONSERVATIVE TREATMENT

K/C/O HYPOTHYROIDISM SINCE 1 YEAR ON THYRONORM 88 MCG

H/O LEFT RADICAL MASTECTOMY RT AND LT 3 YEARS BACK

PERSONAL HISTORY: MARRIED, NORMAL APPETITE, MIXED DIET, REGULAR BOWEL HABITS AND DECREASED URINE OUTPUT, NO KNOWN ALLERGIES, NO KNOWN ADDICTIONS. NO SIGNIFICANT FAMILY HISTORY.

Page-2

KIMS HOSPITALS

GENERAL EXAMINATION:

NO PALLOR, NO ICTERUS, NO CYANOSIS, NO CLUBBING, NO LYMPHADENOPATHY, NO

EDEMA.

VITALS: TEMP- 96.5, BP-150/90 MMHG, PR- 69 BPM, RR-17CPM, SPO2-96% AT RA, GRBS- 142

MG/DL

SYSTEMIC EXAMINATION:

RS- BLAE+, NVBS

CVS- S1S2+, NO MURMURS

CNS- NFND

PER ABDOMEN- SOFT, NON TENDER

DIALYSIS DONE ON 11/10/25, 16/10/25,17/10/25,19/10/25,23/10/25

TRANSFUSIONS DONE ON 17/10/25, 19/10/25

Pulmonology REFFERAL ON 18/10/25 I/V/O Pneumothorax: RT SIDED

HYDROPNEUMOTHORAX, LT PNEUMOTHORAX WITH PNEUMOMEDIASTINUM WITH

SUBCUTANEOUS EMPHYSEMA. - INSERTED B/L ICDS

GENERAL SURGERY REFFERAL: I/V/O GRADE II BED SORE AND RIB FRACTURE: LOCAL

EXAMINATION: A 7X 6 CM SINGLE ULCER OVER GLUTEAL REGION EXTENDING 10 CM

LATERALLY FRO, MIDLINE (FROM SACRUM), MARGINS ARE IRREGULAR, SURFACE APPEAR

SMOOTH, DISCOLOURATION PRESENT, SLOOPING EDGES, FLOOR IS FORMED BY MUSCLE, NO DISCHARGE.

PALPATION: NO LOCAL RISE OF TEMPERATURE, TENDERNESS PRESENT, EDGES ARE

NOT INDURATED, SURROUNDING SKIN IS NORMAL. DIAGNOSED WITH GRADE II BEDSORE.

COURSE IN THE HOSPITAL

Page-3

KIMS HOSPITALS

THIS IS CASE OF 59 YEAR OLD FEMALE K/C/O CKD ON MAINTENANCE HEMODIALYSIS,

PRESENTED WITH C/O BREATHLESSNESS -SUDDEN ONSET AND RAPIDLY DETERIORATED, I/V/O ABSENT CENTRAL PULSES, NON RECORDABLE BP CPR WAS STARTED AND ROSC

ACHIEVED AND PATIENT WAS INTUBATED SIMULTANEOUSLY AND CONNECTED TO MECHANICAL VENTILATOR. POST INTUBATION ASSESSMENT REVEALED LEFT

PNEUMOTHORAX AND RIGHT HYDROPNEUMOTHORAX FOR WHICH PULMONOGY OPINION WAS TAKEN AND IMMEDIATE ICD INSERTION WAS DONE. ALL NECESSARY

INVESTIGATIONS WERE SENT ALONG WITH BLOOD, URINE CULTURES, PLEURAL FLYUID ANALSYSIS. INVESTIGATIONS REVELAED ELEVETAED COUNTS, ANEMIA, DERRANGED

RFT AND LFT 2D ECHO REVEALED SEVERE CONCENTRIC LVH, DECREASED LV FUNCTION, DILATED CHAMBERS. PATIENT WAS STARTED ON ANTI HYPERTENSIVE MEDICATION, ANTIBIOTICS, SEDATION, PARALYTICS AND OTHER SUPPORTIVE TREATMENT MAINTENANCE HEMODIALYSIS SESSIONS WERE CONTINUED ALONG WITH 2 PINT PRBC

TRANSFUSION CONTINUING WITH ABOVE TREATMENT VITALS WERE MONITORED

REGULARLY , SPONTANEOUS BREATH TRIALS WERE DONE FREQUEMTLY AND PATIENT

WAS WEANED OFF FROM VENTILATOR ON DAY 6 OF INTUBATION .SURGERY OPINION

WAS TAKEN I/V/O BED SORE AND ADVISED REGULAR BED SORE DRESSING . POST

EXTIUBATION PATIENT VITALS ARE STBALE THROUGHT OUT COURSE IN THE HOSPITAL

AND IS BEING DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION

Investigation

HEMOGRAM 

9/10/25: HB-6.4 , TLC-7200, RBC-2.3, PCV-19.6, PLT- 2.8...ON 17/10/25 HB-6.1 , TLC-24800, RBC-

2.2, PCV-20.8, PLT- 3....

20/10/25 HB-8.7 , TLC-8400, RBC-3.0, PCV-25.3, PLT- 2.7....

22/10/25 HB-8.8 , TLC-9300, RBC-3.05, PCV-25.7, PLT- 2.95.........

23/10/25:HB-9.3 , TLC-9600, RBC-3.2, PCV-28.3, PLT- 3.6

24-10-2025 HB-8.2G/DL; PCV-24.2VOL%; TLC-14200CELLS/MM3; RBC-2.7MILLION/MM3;

PLATELET COUNT-3.1LAKHS/MM3

CUE: ALB- ++++, SUG- ++, PUS- 3-4, EPI- 2-4, RBC-NIL....ON 22/10/25 ALB- ++++, SUG-NIL, PUS-3-6, EPI- 2-6, RBC-2-3

RFT

17-10-2025 UR-43, CR-4.2, UA-2.30, CA+9.4, P-3.9, NA+-143, K+-5.0, CL-106.....

20/10/25:UR-39, CR-2.4, UA-2.0, CA+9.6, P-2.3, NA+-142, K+-3.5, CL-94....

22/10/25:UR-96, CR-3.90, UA-2.80, CA+10.2, P-4.70, NA+-138, K+-4.1, CL-99.....

23/10/25UR-114, CR-4.20, UA-3.70, CA+9.5, P-6.1, NA+-137, K+-3.8, CL-99...

24-10-2025 BLOOD UREA-58MG/DL; CREATININE-2.60MG/DL; S.Na -137; S.Cl-101; S.K+-2.9.

Page-4

KIMS HOSPITALS

4

LFT

TB-0.70, DB-0.15, SGOT-14 SGPT-19, ALP-249, TP-5.8, ALB-2.8, G-3, AG RATIO-0.93

RBS: 126MG/DL; D DIMER- 450; PT- 17,INR-1.20

SEROLOGY: HIV ,HBSAG ,HCV- NEGATIVE

PLEURAL FUNGAL STAIN: NO FUNGAL ELEMENTS SEEN

BLOOD CULTURE SENSTIVITY N 21/10/25: NO GROWTH AFTER 48 HRS OF AEROBIC

INCUBATION USG CHEST DONE ON 18/10/25: CONSOLIDATORY CHANGES IN B/L LUNG FIELDS

USG ABDOMEN ON 18/10/25: RAISED ECHOGENICITY OF RIGHT KIDNEY.

PLEURAL FLUID CULTURE SENSITIVITY (LT) : FEW INFLAMMATORY CELLS SEEN, NO

ORGANISMS SEEN, NO GROWTH AFTER 48 HOURS OF AEROBIC INCUBATION AT

37DEGREES C .

2D ECHO ON 23/10/25: RWMA + ANTERIOR WALL HYPOKINESIS, CONCENTRIC LVH+, MILD TR WITH PAH, MILD MR, MILD AR, TRIVIAL PR, SCLEROTIC AV, NO AS/MS, IAS- INTACT, EF-52%, RVSP2 38+05 -43MMHG, FAIR LV SYSTOLIC FUNCTION, GRADE I DIASTOLIC DYSFUNCTION+, IVC COLLAPSING, MILD DIALATED LA/RA, MINIMAL PE+AND PLEURAL EFFUSION.

ABG ON 17/10/25: PCO2- 20.80, PO2-115, HCO3-10...ON 23/10/25: PCO2- 41.80, PO2-193, HCO3-

17.

PLEURAL FLUID ANALYSIS (RIGHT)

LDH-126

SUGAR-97

PROTEIN-1.7

PLEURAL FLUID (LEFT)

SUGAR-88

PROTEIN-1.0

Treatment Given(Enter only Generic Name)

RT FEEDS-100ML 4TH HOURLY WITH 2 SCOOPS PROTIEN POWDER ,AND 50ML WATER

SECOND HOURLY,

INJ PIPTAZ 2.25 GM IV TID,

INJ PAN 40MG IV OD

INJ LASIX 60MG IV TID

INJ HEPARIN 5000IV IV QID

INJ TRAMADOL 1 AMP IN 100ML NS IV TID

Page-5

KIMS HOSPITALS

5

INJ OPTINEURON 1 AMP IN 100ML NS IV OD

INJ THIAMINE 100MG IV BD

INJ NEOMOL 1 GM IV/SOS IF TEMP >101.1F

TAB CHYMEROL FORTE 500MG RT/BD

TAB CLONIDINE 0.1 MG RT TID1-1-1

TAB NICARDIA 20MG RT TID 1-1-1

TAB PRAZOSIN 5 MG RT OD 0-1-0

TAB MET-XL 75 MG RT OD 0-1-0

TAB ECOSPRIN GOLD 75/75/20MG RT HS 0-0-1

TAB THYRONORM 88 MCG RT OD 1-0-0

NEB WITH IPRAVENT 6TH HOURLY, BUDECORT 12TH HOURLY, MUCOMIST 12TH HOURLY,

FREQUENT POSITION CHANGE, CHEST PHYSIOTHERAPY 12TH HOURLY, GRBS

MONITORING 4TH HOURLY, REGULAR DRESSING OF BED SORE, MUPIROCIN 2%OINT FOR L/A BD,

Advice at Discharge

FLUID AND SALT RESTRITION

TAB AMOXICLAV 625 MG PO B FOR 5 DAYS

TAB PAN 40MG PO OD FOR 5 DAYS

TAB NICARDIA 20MG PO TID TO CONTINUE

TAB CLONIDINE 100MCG PO TID TO CONTINUE

TAB PRAZOSN 5 MG PO BD TO CONTINUE

TAB MET XL 75 MG PO OD AT 2 PM TO CONTINUE

TAB DYTOR 20MG PO BD 8AM - X 4PM TO CONTINUE

TAB NODOSIS 1000MG PO BD FOR 15 DAYS

TAB OROFER XT PO OD 1-O-O FO 3 MONTHS

TAB REJUNEX CD3 PO OD FOR 15 DAYS

Follow Up

REVIEW AFTER 2 DAYS TO NEPHRO OPD FOR MHD SESSIONS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

 For Treatment Enquiries Patient/Attendant Declaration: - The medicines prescribed

and the advice regarding preventive aspects of care, when and how to obtain urgent care have been

explained to me in my own language

SIGNATURE OF PATIENT /ATTENDER

SIGNATURE OF PG/INTERNEE

SIGNATURE OF ADMINISTRATOR

SIGNATURE OF FACULTY

Discharge Date

Date: 24/10/2025

Ward: AMC

Unit: NEPHROLOGY